Current Practice and Screening for Deep
Vein Thrombosis and Pulmonary Embolism:
Keeping Up With the Evidence.
John Heick, PT, DPT, OCS, NCS
Jim Farris, PT, PhD
Arizona School of Health Sciences
A.T. Still University, Mesa, Arizona
Disclosure
• We have nothing to disclose as no relevant financial
relationship exists.
Learning Objectives
– After this session, you will be able to:
• 1. Identify the pathology leading to formation of a DVT and PE.
• 2. Discuss the morbidity and mortality related to DVT.
• 3. Compare and contrast signs and symptoms related to differential
diagnosis of a DVT to a PE.
• 4. Analyze the models of assessment for identifying a DVT.
• 5. Introduce clinical algorithms for PE to guide clinicians for
intervention decisions.
• 6. Critically evaluate the use of Homan’s sign.
• 7. Discuss current practice related to interventions of a patient with a
DVT and PE.
• 8. Advocate for the use of clinical decision rules and clinical practice
guidelines in evaluating and providing interventions for patients with
a DVT or PE.
Poll
Questions to Ponder
Session Outline
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Identify pathology of DVT & PE
Analyze model of assessment for identifying a DVT
Critically evaluate the use of Homans sign
Introduce clinical algorithms for PE to guide clinicians
Case studies
Implementing guidelines
Discussion
Introduction to Pathology of VTE
• VTE refers to all forms of thrombosis in the venous
circulation and manifests in 2 ways: deep vein thrombosis
(DVT) and pulmonary embolism (PE).
• DVTs affect ~ 2 million Americans per year, is the 3rd most
common cardiovascular disease after CAD and stroke, and
PE are responsible for 10% of hospital deaths. Anand et al 1998;
Autar, 1996
VTE
– Can occur in any vein, most
common in the legs
– If superficial, then usually
varicosities, benign & selflimiting
– Long saphenous vein
thrombosis extends into
deep veins (DVT)
– DVT localized in the calf
veins are often small & less
commonly associated with a
PE
– Associated with significant
morbidity
Initiation of a Thrombosis
• Venous stasis
– Immobility
– Venous obstruction
– Increased venous pressure
– Venous dilation
– Increased blood viscosity
DVT
• Proximal DVTs involve the popliteal, femoral, or iliac
venous system.
• Approximately 20% of untreated silent calf vein thrombi
and 20% to 30% of untreated symptomatic calf vein
thrombi extend into the popliteal vein.
• When the DVT extends and is untreated, it is associated
with a 40% to 50% risk of clinically detectable PE. Anderson FA
• VTEDVTPE
– Important causes of morbidity and mortality in hospitalized
patients.
– VTE also occurs spontaneously in healthy, ambulatory
outpatients.
Anderson FA.
PDVT
• Proximal deep vein thrombosis (PDVT) is the more
dangerous form of lower-extremity DVT because it is more
likely to cause life-threatening PE and may result in a
greater risk of postthrombotic syndrome. Riddle & Wells 2004
• Calf DVT, although less serious than PDVT, must be
considered because the thrombus extends proximally in
approximately 30% of cases. Riddle & Wells 2004
PE
• ~ 10% of all patients with
acute PE die during the
first 1 to 3 months after
diagnosis.
• Overall, 1% of all patients
admitted to hospitals die of
acute PE, and 10% of all
hospital deaths are related
to a PE.
Stein 2010
DVT incidence trends
• From 1989-2006, hospital DVT increased 3.1 times
from 35 to 107/100,000 population. Stein 2010
• From 1992-2006, the incidence of PE in hospitalized
patients increased 2.5 times from 33 to 83/100,000
population. Stein 2010
– The incidence of a secondary diagnosis of PE increased at a
lower rate.
• Stein concluded that “Efforts to prevent DVT in highrisk hospitalized patients appear to be inadequate.
Therapy of DVT, however, appears to be effective.”
DVT trends: Stein 2010
• The proportion of hospitalized patients with DVT
has decreased as a result of early discharge home.
• The incidence of PE increases exponentially with
age, but no age group is immune.
• Asians and Native Americans have a lower
incidence of PE than whites or African Americans.
• Epidemiologic data and new information on risk
factors provide insight into making an informed
clinical assessment and evaluation for
antithrombotic prophylaxis.
Risk factors for DVT
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Previous venous thrombosis or embolism
Age, over 55-60 years
Active cancer or cancer treatment
Severe infection
Oral contraceptives, hormonal replacement therapy
Pregnancy or given birth within the previous six weeks
Immobility (bed rest, flight travel, fractures)
Surgery, anesthesia
Critical care admission, central venous catheters
Inherited thrombophilia
Obesity
One or more significant medical comorbidities (for example: heart
disease; metabolic, endocrine or respiratory pathologies; acute
infectious diseases; inflammatory conditions, peripheral arterial
insufficiency)
Clinical manifestations of a PE
• S&S of VTE are caused by obstruction to venous outflow,
inflammation of the vessel wall or perivascular tissues, or
embolization of thrombus into the pulmonary circulation.
• Most clinically significant and fatal PE probably arise from
thrombi in the proximal veins of the legs.
• Asymptomatic PE is detected by perfusion lung scanning in
approximately 50% of patients with documented proximal
vein thrombosis.
Clinical manifestations of a PE
• Although PE also may complicate calf vein
thrombosis, these emboli tend to be smaller
in size, and PE occurs less commonly than in
patients with proximal vein thrombosis.
• Asymptomatic VTE is found in 70% of
patients who present with confirmed PE.
These thrombi usually are large and involve
the proximal veins.
Clinical manifestations continued
• In approximately 70% of patients
referred for clinically suspected venous
thrombosis, the diagnosis will be excluded
by objective tests.
• Of the 30% who have VTE,
approximately 85% will have proximal
DVTs and the remainder will have
thrombosis confined to the calf.
Signs & Symptoms
• The classic signs and symptoms of DVT are
localized pain, tenderness, swelling, and
discoloration.
• Other symptoms may include lower extremity
edema, fever, extremity warmth, and pain.
– Symptoms can serve only as a trigger for further
diagnostic inquiry; they cannot, by themselves, rule a
DVT in or out.
• Like symptoms, physical examination findings are
not sensitive or specific; in more than 50% of the
instances in which there was a verified DVT, there
was a normal physical examination.
Signs & Symptoms
• Most clinicians attempt to identify outpatients
suspected of having PDVT by considering the
patients’ signs and symptoms and associated risk
factors. For example, patients with symptomatic
PDVT tend to complain of lower extremity pain,
calf tenderness, and lower extremity swelling.
• However, approximately 75% of all patients who
are suspected of having PDVT are found not to
have PDVT when formal diagnostic testing is
completed.
Riddle & Wells 2004 article
Other conditions to consider
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•
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Malignant disease
Morbid obesity
Previous history of VTE
Stroke
Irritable bowel syndrome
Congestive heart failure
Pregnancy
Advanced age
Hereditary conditions
–Include deficiencies in protein C and protein S and
familial thrombophilia.
Differential Dx of DVT
• Common conditions that mimic a VTE:
• Muscle hematoma
• Muscle or tendon tear
• Muscle cramp
• Superficial thrombophlebitis
• Postphlebitic syndrome
• Cellulitis
• Sciatica
• External venous compression
Conditions that may mimic symptoms
associated w/ pDVT
 Musculoskeletal : trauma, hematoma, myositis, tendinitis,
Baker’s cyst, synovitis, osteoarthritis, osteomyelitis, tumors,
fractures
 Neurological : sciatica, lower-limb paralysis
 Venous: phlebitis, postthrombotic syndrome,
compressed veins
 Arterial : acute arterial occlusions, a-v fistula
 Generalized: edema, cardiogenic, nephrogenic, dysproteinemic
 Cutaneous: dermatitis, cellulitis, lipoedema, panniculitis
 Localized: edema, pregnancy, oral contraceptive intake, limb
immobilization
Prandoni P, Mannucci PM. 1999.
Current practice evolving
• Current practice is to refer all patients presenting with
complaints suspected of a DVT, to specialized diagnostic
services for objective testing.
Studies have revealed that 80–90% of these referred
patients do not have a DVT.
• Rapid point-of-care D-dimer assays combined with a
specific CDR makes it possible to realize a diagnostic workup in a primary care setting.
ten Cate Hoek 2009
Sensitivity & Specificity
• Given that PDVT is a serious disorder with
potentially life-threatening consequences, tests
used by physical therapists to identify patients with
PDVT should have a very high sensitivity
(proportion of patients with the disorder who have
a positive test) so that negative tests would indicate
that the clinician can confidently rule out the
disorder.
Riddle & Wells 2004
Sensitivity & Specificity
• False negative tests would be potentially catastrophic in this
case because the patient would actually have a PDVT even
though the test result was negative.
• The therapist would potentially falsely conclude that
referral to a physician is unnecessary.
Riddle & Wells 2004
Homans sign
In Our Current & “Classic” Texts
Homans’ Sign Evaluated
(Urbano, 2001 - review)
• Homans’ sign present in 33% pts with thrombosis, also present
in 21% without
• Estimates of accuracy of Homans’
– positive in 8% to 56% of proven DVT cases, positive in 50% of
symptomatic pts without proven DVT
– More common in pts clinically suspected of DVT with negative
venogram than in clinically suspected with positive venogram
• “This has led nearly all authors to declare that Homans’ sign in
unreliable, insensitive, and nonspecific in the diagnosis of
DVT.”
(Urbano, FL. Homans’ sign in the diagnosis of deep vein thrombosis.
Hospital Physician. March 2001, pp. 22-24)
Wells CDR
• “The diagnosis of DVT relies heavily on the use of objective
tests because signs and symptoms are not thought to be
specific.”
• “It has been our impression that clinical features can be
used to classify symptomatic patients with suspected DVT
as having a high or low probability for DVT before
diagnostic testing.”
Clinical Pretest Probability - Wells DVT Score
Active cancer (on treatment for last 6 months or palliative)
1
Paralysis, paresis or plaster immobilization of lower extremity
1
Immobilization previous 4 days or major surgery within 4 weeks 1
Entire leg swollen
1
Calf swollen by more than 3 cm
1
Pitting edema
1
Collateral superficial veins (non-varicose)
1
Probable alternative diagnosis
-2
-------------------------------------------------------------------------------------------High DVT Risk = 3+
Moderate DVT Risk = 1-2
Low DVT Risk = < 1
(If both legs are symptomatic, score the more severe leg)
CURRENT Wells CDR (2-level)
Active Cancer (ongoing treatment, w/in 6 months or
palliative)
1
Paralysis paresis or recent plaster immobilization of
LE’s
1
Recently bedrest 3 days or > or major surgery w/in
12 weeks requiring general or regional anaesthesia
1
Localized tenderness along deep venous distribution
1
Entire leg swollen
1
Calf edema @ least 3 cm larger than asymptomatic
side
1
Pitting edema confined to symptomatic side
1
Collateral superficial veins (non-varicose)
1
Previously documented DVT
1
Alternative diagnosis at least as likely as DVT
-2
Clinical probability simplified score
DVT ‘likely’
DVT ‘unlikely’
2 points or more
Less than 2 points
Padua CDR for Hospitalized Patients
Active Cancer*
3
Previous VTE (excludes superficial vein
thrombosis)
3
Reduced mobility**
3
Already known thrombophilic condition
3
Recent (<1 month) trauma/surgery
2
> 70 years old
1
Heart and/or respiratory failure
1
Acute MI or CVA
1
Obesity (BMI > 30 kg/m)
1
Ongoing hormonal treatment
1
High risk > 4
*Patients with local or distant metastases and/or in
whom chemotherapy or radiotherapy had been
performed in the previous 6 months.
**Bedrest with bathroom privileges for @ least 3 days
Wells Rule for PE
Clinical signs & symptoms of DVT
3.0
Alternative diagnosis less likely than PE
3.0
Heart rate > 100
1.5
Immobilization > 3 days or surgery in past 4 weeks
1.5
Previous PE or DVT
1.5
Hemoptysis
1.0
Cancer (tx in last 6 months)
1.0
Clinical probability of PE
Low
<2
Intermediate
2 to 6
High
 6
Alternate scoring
Unlikely
<4
Likely
>4
Revised Geneva Rule for PE
Age > 65
1
Previous PE or DVT
3
Surgery or fx of LE’s in past month
2
Cancer (active or cured < 1 year
2
Unilateral LE pain
3
Heart rate
75 to 94 bpm
> 95 bpm
3
5
Hemoptysis
2
Pain on deep venous palpation of LE & unilateral
edema
4
Clinical probability of PE
Low
Intermediate
High
<4
4 to 10
> 10
Clinical algorithm for PE
Suspect PE
Clinically unstable?
Consider
Massive PE
NO
Estimate clinical Pretest
Probability Using CDR
>6
<4
5-6
PERC
positive?
NO
YES
YES
CT
angiogram
Begin
Anticoagulation
PERC
positive?
CT
angiogram
YES
NO
NO
PE
unlikely
YES
D-dimer
Ddimer?
Reassess
likelihood of
PE
NO
PE
unlikely
PE
confirmed
Case studies
Implementing guidelines
Discussion
[email protected]
[email protected]
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